trauma

This is getting better. I got to do another bronchoscopy today, and actually saw something useful (instead of just getting the scope jammed inside the tube and not being able to move; while the attending kept saying, “You see the carina? Go down the right side, ok, now go down the left side. . .” while I wasn’t actually moving at all, and then wanted to know why I wasn’t done already).

The rest of the residents want to know why it’s always my patients who need all the procedures. Somehow, I’ve managed to do almost all the procedures so far this month, without actually stealing anything from them. I wouldn’t mind if my patients would stop crashing, but I’m not controlling that. I need to make an effort not to pick up the sickest of the new patients every morning, so we can share the excitement.

At one point there were enough traumas coming in (as a general principle, men over 70 should not be allowed to climb ladders, and people over 90 should not be allowed to walk on stairs) that I was admitting by myself again. I got the sweetest little old lady, who very calmly coped with us running all around her in the trauma bay, and told me, “There’s nothing wrong with me, sweetheart. I know you need to check, but I’m really just fine. No, I never had any surgeries. I usually don’t come to the hospital, you see, until lately. No, nothing’s hurting me. I told you there’s really nothing wrong, you don’t have to worry.” There was something wrong (little old ladies over 70 always break something when they fall), but hopefully it won’t be too serious, especially since her first words, when I told her the bone was broken, were, “I’m not going to have surgery, ever, no matter what, so that settles it.”

The fun part was when her daughter came in to see her, and it turned out that I’d spent several nights, one night float month, dealing with this daughter’s post-operative complications. One night she’d have low urine output, another night an arrhythmia; then she got an ileus and was throwing up and I had to put in an NG tube; and so on and on, till I finally got off night float before she left the hospital. She was quite well now, and told her mother everything would be fine, she knew the doctor. It was sweet, but also a little daunting, that I’ve been in one hospital so long that I’m starting to treat families. I wasn’t expecting quite this much continuity in surgery residency.

I don’t know whether it’s good for my patients or bad for me, but today was the first time I had to make the decision to intubate a patient. (Other times, the decision had already been made.) It was actually pretty straightforward: RN: “Alice, the patient’s sats are in the 80s, and I can’t make them come up.” Alice: “I see you have him on a nonrebreather mask and have been suctioning him. Sir, can you open your eyes? Can you talk to me? No. Ok, the sats are dropping further, let’s start bagging, let’s call anesthesia.” Done. It’s usually a bad sign when you can intubate without paralytics or sedatives. Then we spent the rest of the day trying to figure out which came first, the chicken or the egg: the altered mental status or the respiratory failure.

Next time, if the aggressive chief is around, we might skip the “call anesthesia” part. At this hospital, anesthesia residents are always available (although available might mean 10-15 minutes away, not always good in a less controlled code than this one was), so the intubations are almost always done by them. But the equipment is there in the ICU, and there’s something to be said for knowing how to intubate when you have to. Of course, there’s never a good time to learn. Where I went to school, there were no anesthesia residents, and the surgery residents were responsible for intubating any time a code was called, or for trauma patients in the ER – so they learned pretty quickly.

Also for the first time I supervised another resident putting in a subclavian line. I’d tried to supervise before, but my tolerance level for teaching on awake patients is still pretty minimal. We both did better with the patient intubated and sedated.

I think I’m turning into “friendly reference material” for the interns, since they can be pretty sure I won’t mock them if they ask questions. I’m afraid I’m also behaving like a mother hen, trying to help some of the weaker interns who are getting picked on. I’m not sure I’m approaching the situation correctly, and I hope that I know enough myself that my advice doesn’t end up getting them in more trouble. I also wonder whether my kindness doesn’t undermine the high demands inherent in surgical residency; eventually, patients will die if you make the wrong choices, and getting a harsh response to a stupid answer is only preparation for that. But I figure there are enough men around here who will provide that aspect, it shouldn’t unbalance things too much if some of the women adopt a gentler approach.

Me deciding to address all the attending’s pet peeves by acting on them before he did. Result, the nurses were mad at me as well as him, and I don’t think I saved much time. It did make the attending happy, though.

Attempted bronchoscopy: Attending: “Sure, you can do it with me. Have you ever done any of these before?” Me: “Yes, definitely. (sotto voce Twice, to be precise.”) Attending: “This is how it’s done, bzzzbtttbzzz (words all blurred together). Ok, go.” So whatever I remembered from the previous two times disappeared, between the attending being not wanting to do it at all, and being in a hurry, and the patient actually having a problem.

For my commenters: Attending: “Anesthesia left the a-line hanging loose again. Suture it in right now.” Me: “Yes, let me find some suture. Um, I once heard a rumor that suturing radial a-lines promotes infection and thrombosis. (Although my literature search showed nothing of the sort.” The attending looked at me as though I had just sprouted an extra head. (Note to self, not to refer to blog commenters anymore unless accompanied by evidence.)

Taught three different people how to place post-pyloric feeding tubes – on the same patient, because every time we got one in, confirmed placement, and start feedings, he’d get it out by yet another method.

And spent all spare minutes trying to adjust the ventilator settings on the sickest patient in the unit, who has all kinds of unusual methods being tried on him, and none of them are working. Only two doctors in the unit really understand his respiratory status, and of course they’re not there all the time. I perhaps flatter myself in thinking that I understand a little of their methods, certainly more than the people who say, “I have no idea why he chose these settings, I don’t understand the rationale at all, let me tweak it a little.” So all day long the people who did have a clue would walk by and laugh bitterly at my blood gases, and inquire why it was taking me all day and I hadn’t done x/y/z obvious thing to correct the glaring abnormalities. Thanks for the help, folks.

I’ve spent so much time in the hospital lately that coming out into the sunlight feels like culture shock: there is light like this around commonly?

I’ve figured out (belatedly, perhaps) that the hard part of call is only between midnight and 5am. That’s when the circadian rhythm really demands to slow down and go to sleep. Before, and even after, is not that bad. In fact, looking at the sunlight now makes me feel fairly wide awake, although I know i’ve missed so much sleep lately that if I don’t catch up on at least a fraction of it today, the rest of the week will be ruined.

Part of it, too, is the discipline we started learning back in grade school math: I don’t want to finish these problems, to pay attention and work all the way through, but I will anyway. At a certain point in the night, I really do not want to be there at all. It would be so delightful to simply walk away; not even out of the hospital, just into the callroom, and decide to ignore pages for an hour or two, or even just to ignore the jobs that ought to be done even though no one will page about it (checking labs and imaging ordered earlier, walking around to check on the critical patients, filling out some of the mountains of paperwork that have to be done at night because if saved for daylight they’ll overwhelm the team’s resources). But I won’t; I’ll keep going regardless of what I’d like to be doing.

There’s a point in the middle of an endless stream of traumas, one or two every fifteen minutes, where every single person in the ER looks at the others and says, “Why am I here, and why am I doing this?” And no one has much of an answer, so someone says something flippant, and we keep going. Or a patient threatens to leave AMA, and we all shrug: Sure, do us a favor, the door is that way.

Then there was the time I decided to put my head down on the desk for five minutes, and when the nurse came to ask me about something, I jumped so hard she was more startled than I was. I think I have too much of a startle reflex. I’d been half-awake the whole time, knowing it was a matter of minutes before someone needed something from me, and I still leaped to my feet. I’m usually a very solid sleeper, but I’ve trained myself to never really sleep in the hospital. I’m too worried about the consequences (to a patient, or to my career) if I sleep through a page. So I’m always half listening, and waking up every now and then to check the pager and make sure I didn’t miss anything. Which makes me rather unsympathetic to the new medical students and interns who do occasionally sleep through their pagers. I can have slept 4 hours in the last 48, and still jump up the second my pager goes off.

I forgot how much I hated, er, didn’t like, trauma. It’s pleasant to be back in a closed unit where the nurses recognize me, and most of them seem to like me (as in, they’re very happy to have me back around because I do scut the fastest, like reordering meds, and fixing orders that other people put in wrong, or coming quickly when they want someone to look at the patient).

On the other hand, as I said, I forgot how much I hate rounding all day. This weekend, fortunately for all who are interested in my sanity, the most annoying attendings are not rounding. The one who was, however, has certifiable ADD; so does the chief; and I come close, especially in their company. Neither of them can finish a sentence, let alone a train of thought, without jumping to something else, and then jumping back halfway through. The chief and I get along well, because I’m just scatterbrained enough to follow his jumps, and guilty of it enough myself that I can’t get as annoyed with him as other people do. (Incidentally, I don’t believe in ADD either; but it’s a convenient label that lets you all know what I mean.)

But rounds with the three of us was kind of crazy. I’d recite all the facts on a patient, the attending scribbling away and giving a very good impression of listening. Then he’d give some orders about the patient we’d just walked away from, run into the next room to check on something, come back, and ask me whether I’d mentioned a blood pressure or a fever on the patient, and what did the CT results show? So I would repeat what I had just told him. “Let me see the chest xray. Oh good.” Run back into the room to look at the pulse ox. Back out. “We need to start tube feeds. What’s the white count? Did we order a CT for the last guy? Has this person had a head CT recently? Is neurosurgery going to come see the guy down the hall?” And every time you start an answer, he moves on to the next one, then comes back, impatient because you haven’t answered the last several questions.

It works ok, because we’re all conscientious enough to make notes, and keep coming back to go over things until it all gets covered. But it does get a little wearing, and the nurses were left standing there with a dazed look, saying, “Were you talking about my patient at all, and if you were, did you decide to do anything important?”

Correction to the last post: I guess there was one attending in the group whom I didn’t totally antagonize. If we were playing a game of “pick one attending you’d like to be on the good side of,” I’d have chosen him, since he’s powerful, and has a very sharp tongue when he’s displeased. Actually, I don’t know how, I seem to have impressed him well enough that as I spent the morning stumbling through rounds, he remarked a couple of times: “I know Dr. Alice is a very good resident. In fact, she’s one of the best we’ve had all year. I don’t know what’s happened to her this morning, but I guess we can excuse her for one day.” Mmm, thanks; I suppose there’s a limit to how many days I can work straight, no time off, pushed to the limit, pulled in a dozen different directions for critically ill patients every ten minutes, without starting to crack a little bit. So I picked a good attending to stay friendly with.

In other ways, this day has to have been one of the worst of the year. More than one patient with seriously bad outcomes, which are maybe somehow someone’s fault. I can’t honestly tell whether it’s truly my fault, but I keep getting caught in this whirlpool: I should have done something different, I really should have; could I have changed this? was it physically possible for me to be in enough places to have caught this? I should have known; I should have, I should have. Some of the more senior residents saw me standing still, I guess looking as miserable as I felt, and made some remarks that I shouldn’t get too personally involved with the patients. I told them briefly what had happened, and they backed up. “Well, as bad as that, ok.”

All year, when I breezed through things, the seniors and chiefs have told me, “We’re paranoid, and after you have enough patients get hurt around you, you’ll be paranoid too.” The last month I think does it for me, and especially the last few days. Now I know why the best doctors here are obsessive about every single detail – because you never know which detail is going to come back to bite you, maybe to kill or maim your patient.

The best junior residents I’ve watched all year were the ones who came in early and stayed late, even when they were working night shift, or post-call, to double-check on things, and watch over patients till the oncoming team had thoroughly grasped the situation. Now I know what drives them, and I resolve to simply stop caring what time of day it is. I’ll mark my hours how I please, but I’ll stay, every single time, till I know all the details, till the next team knows all the details. Nothing outside of the hospital matters compared to making sure I’ve done the best possible for every person I’m responsible for. I am sick of seeing what can happen when things slip through signout; perhaps more precisely, I’m sick of worrying about whether something slipped.

On the other hand, as I contemplate being on call the Fourth of July (I was expecting that; given the small number of junior residents, and the surgical attitude of “throw them in the deep end and see if anyone figures out how to swim,” I knew I was going to be on call very early in the month), I realize that this month, as nightmarish as it’s been, has made me feel very comfortable with handling all kinds of calls about ICU patients, and semi-comfortable with the prospect of juggling admissions, consults, and disasters by myself. I guess there’s an element of familiarity about it too: I’ve been looking ahead to this kind of responsibility for a year, and I think I know better what’s expected of me (if not what I should expect) than I did heading into internship. (Now if various seniors would just stop making rueful remarks about me being a junior in three days. I can’t tell if they’re serious or not, or how concerned they are.)

Thanks everyone for the encouraging comments. I think things are getting better overall; I can handle four more days.

Today continued to be splendid. My efforts to discharge patients to the floor succeeded mainly in disgruntling the floor staff, and led to one of my . . . episodes . . . with an attending today. All the hard work didn’t do me much good, because we just admitted more patients through the ER as fast as I could discharge them to the floor.

Yes, I seem to have ticked off every single attending in this group – three of them today. That has to be some kind of record for the worst resident performance ever, wouldn’t you think? With one of them I really did something wrong – forgot something that a resident four days away from being a responsible junior resident shouldn’t forget. That was very bad, dangerous even. As everyone within hearing range pointed out to me, I can’t do that stuff as a junior resident, I have four days to mend my ways, and I’d better watch out. And I have to agree with them, which feels worse..

The other two attendings, I don’t know what happened. Apparently I’m such a bad communicator that even when I say, “Yes, sir, absolutely,” meaning, “Yes, sir, absolutely,” it comes across as “No way, you #$*&^, why are you even asking me? &^%” Or that’s what the attendings told other people they thought I’d said. Which is pretty hopeless. Because if a nurse is angry, and I respect her, I can go talk, and we usually sort it out. But there’s absolutely nothing an intern can say to an attending even by way of complete apology that doesn’t make everything worse. My latest plan is to say nothing but “yes” in the most colorless voice I can come up with, to anything that anyone says to me (except requests for pain medicine). I’m sure the only attending I haven’t infuriated yet will perceive this as incompetence combined with negligence, and then I’ll have antagonized a quarter of the attendings at this hospital. Brilliant, Alice.

On a brighter note, I took care of some sick patients today, and except for that one really disastrous oversight (ahem) did ok; a lot better, I think, in the department of not panicking when patients are screaming and blood pressures are dropping. I certainly refrained myself from paging people and suggesting calling the OR, which is a key technique (since the junior residents are relied on, at night, to sort out who needs surgery and who doesn’t, and when an attending needs to be called in from home, or not).

Four days to go, and then, as everyone as explained to me, I’ll really be in trouble, so much so that this month will look like cake. At least that stops me worrying about hospital politics, and gets me back to considering how incompetent I may be, which is slightly more cheerful, because it’s at least within my control.

Disclaimer

Patients described here are purely fictitious, and any resemblance to actual persons is entirely coincidental. The theology, on the other hand, is very much for real.
Please see a real live doctor for any personal medical concerns.